Provider Demographics
NPI:1982803615
Name:CARROLL W POOVEY JR OPTOMETRIST
Entity Type:Organization
Organization Name:CARROLL W POOVEY JR OPTOMETRIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARROLL
Authorized Official - Middle Name:WILBURN
Authorized Official - Last Name:POOVEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:540-381-3366
Mailing Address - Street 1:PO BOX 648
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24068-0648
Mailing Address - Country:US
Mailing Address - Phone:540-381-3366
Mailing Address - Fax:540-381-2007
Practice Address - Street 1:2400 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-1088
Practice Address - Country:US
Practice Address - Phone:540-381-3366
Practice Address - Fax:540-381-2007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000105152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009237399Medicaid
VA1699785972OtherINDIVIDUAL NPI
VA1699785972OtherINDIVIDUAL NPI
VA009237399Medicaid